PSEO State Form Tips Once completed, you can scan/e-mail to us at [email protected] or fax to 651-631-5680. POSTSECONDARY ENROLLME N T OPTIONS P ROGRAM ED-01763-17 NOTICE OF STUD E N T REGISTRATION 2016-17 NOTE: Complete an enrollment form for each instructional term and postsecondary institution the student attends. Once Sections 1, 2, and 3 are completely filled out, mail the enrollment form to the postsecondary institution. Do not mail this form to MDE. We will fill in your college ID once submitted to us. College Student ID Number: ________________________________ Be sure to write your birth date, not today’s date! 1. TO BE COMPLETED AND SIGNED BY THE STUDENT & PARENT/GUARDIAN Student Name (Last, First, M.I.) Even if you are looking into doing PSEO at more than one institution, put University of Northwestern. When you fill out another state form for the other institution, you would put their name in then. Select Gender M F Date of Birth (MM/DD/YYYY) ___________________________________________________________________________________________________________ Street Address: City: Zip Code: Telephone Number: ___________________________________________________________________________________________________________ Postsecondary Institution This Term: Parent/Guardian Name: Address (if different than above) ___________________________________________________________________________________________________________ Minnesota Statutes, section 124D.09, subd. 6,requires students and parent/guardian sign a statement indicating they have received information about the program, are aware counseling services are available and understand the responsibilities regarding enrollment in postsecondary courses. We have received the information required under Minnesota Statutes, section 124D.09, and are aware the student above is enrolling in postsecondary courses. ___________________________________________________________________________________________________________ Student Signature Parent/Guardian Signature (if student is under 18) Date Upon completion of Section 1, pass this form to the pupil’s secondary school for completion of Section 2 2. TO BE COMPLETED BY SECONDARY/NON-PUBLIC/HOME SCHOOL Make sure to sign! Must be hand-written. Electronic signatures not accepted. Parent signature is not required if student is 18 or older University of Northwestern only offers PSEO to high school juniors and seniors. The only institutions to offer earlier are a few public institutions with limited offering. Secondary/Non-Public/Home School Name School Type – Select One Public or Non-Public or Home School Only applicable for Public School students. Student’s MARSS Number ___________________________________________________________________________________________________________ Attending School District Name Attending School District # Resident District Name Resident District # ___________________________________________________________________________________________________________ Student’s grade while attending this Postsecondary Institution Grade 9 Grade 10 Grade 11 Grade 12 Select grade level Public only Public only NOTE: HIGH SCHOOL GRADUATES AND 21 YEAR OLDS ARE NOT ELIGIBLE ___________________________________________________________________________________________________________ Students may not enroll in PSEO courses in addition to a full high school class load. Does this student have at least one free class period during the high school day? (select one) Yes No Is the above student eligible for program application? (See page 3 for requirements) (select one) Yes No SECONDARY/NON-PUBLIC/HOME SCHOOL VERIFICATION I certify the student identified in Section 1 meets the eligibility requirements outlined in Minnesota Statutes, section. 124D.09, to apply for participation in the Postsecondary Enrollment Options (PSEO) program this term, and the information in Section 2 is accurate and applicable to the student. Secondary School Contact Name Contact Signature Email Address Telephone Date ___________________________________________________________________________________________________________ Directions: Upon completion of Section 2, pass this form to the postsecondary institution for completion of Section 3. Again, make sure school signs! Must be physical signature. Electronic signatures not accepted. Home School students only need to provide their residential district name and number; Public and Private School students only need to provide their attending school district name and number. Make sure to answer each question! PSEO State Form Tips Once completed, you can scan/e-mail to us at [email protected] or fax to 651-631-5680. POSTSECONDARY ENROLLMENT OPTIONS NOTICE OF STUDENT REGISTRATION ED-01763-17 Student Name (Last, First, M.I.) We fill out this portion, so don’t worry about it! Date of Birth (MM/DD/YYYY) PAGE 2 College Student ID Number ___________________________________________________________________________________________________________ 3. TO BE COMPLETED BY THE POSTSECONDARY INSITUTION Name of Postsecondary Institution City of Postsecondary Institution __________________________________________________________________________________________________________ _ Term of planned attendance Semester 1 Semester 2 Qtr. 1 Qtr.2 Qtr.3 Select one ___________________________________________________________________________________________________________ Postsecondary Institution Contact Name Email address Telephone ___________________________________________________________________________________________________________ COURSES TAKEN FOR SECONDARY CREDIT COURSE NUMBER COURSE CREDITS Course #1 _________________________________ _______________________ ____________________ Course #2 _________________________________ _______________________ ____________________ Course #3 _________________________________ _______________________ ____________________ Course #4 _________________________________ _______________________ ____________________ Course #5 _________________________________ _______________________ ____________________ Course #6 _________________________________ _______________________ ____________________ I certify the student identified in Section 1 is registered this term for the courses indicated above, all courses are non-sectarian in content, are not remedial or developmental, and the student has indicated to me the courses are to be taken for secondary credit. ___________________________________________________________________________________________________________ Signature-Postsecondary Institution Contact Person Title Date REQUIRED UNDER MINNESOTA STATUTE, SECTION 124D.09, SUBD. 5 “If an institution accepts a secondary pupil for enrollment under this section, the institution shall send written notice to the pupil, the pupil’s school or school district, and the commissioner within ten days of acceptance. The notice must indicate the course and hours of enrollment of that pupil.” The postsecondary institution must mail a copy of this form, within ten days of acceptance, to the following address: Minnesota Department of Education, Division of School Finance,1500 Highway 36 West, Roseville, MN, 55113. Additionally, copies of the completed form must be sent, within ten days of acceptance, to the student indicated in Section 1 and the secondary school of attendance indicated in Section 2. PSEO State Form Tips Once completed, you can scan/e-mail to us at [email protected] or fax to 651-631-5680. POSTSECONDARY ENROLLMENT OPTIONS PROGRAM STUDENT ELIGIBILITY - Minnesota Statutes, section 124D.68 and section 124D.09 th An 11 or 12 grade pupil enrolled in a Minnesota public, nonpublic, home school or American Indian-controlled tribal contract or grant school eligible for aid under section 124D.83, except a foreign exchange pupil enrolled in a district under a cultural exchange program, may apply to an eligible institution to enroll in nonsectarian courses offered by that postsecondary institution. th th A 9 or 10 grade pupil enrolled in a district or an American Indian-controlled tribal contract or grant school eligible for aid under section 124D.83, except a foreign exchange pupil enrolled in a district under a cultural exchange program, may apply to enroll in nonsectarian courses offered under 124D.83, subd. 10, if (1) The school district and the eligible postsecondary institution providing the course agree to the student’s enrollment or th th (2) The course is a world language course currently available to 11 and 12 grade students, and consistent with section 120B.022 governing world language standards, certificates, and seals. Career and Technical Education (CTE) courses offered by a Minnesota state college or university th th th A 10 , 11 , or 12 grade pupil enrolled in a district or an American Indian-controlled tribal contract or grant school eligible for aid under section 124D.83, except a foreign exchange pupil enrolled in a district under a cultural exchange program, may enroll in a career or technical education course offered by a Minnesota state th college or university. A 10 grade pupil applying for enrollment in a career or technical education course must th have received a passing score on the 8 grade Minnesota Comprehensive Assessment (MCA) in reading as a th th condition of enrollment. A current 10 grade pupil who did not take the 8 grade MCA in reading may substitute another reading assessment accepted by the enrolling postsecondary institution A. Limit on Participation: 1) A pupil who first enrolls in grade 9 may not enroll in postsecondary courses for more than the equivalent of four academic years. 2) A pupil who first enrolls in grade 10 may not enroll in postsecondary courses for more than the equivalent of three academic years. 3) A pupil who first enrolls in grade 11 may not enroll in postsecondary courses for more than the equivalent of two academic years. 4) A pupil who first enrolls in grade 12 may not enroll in postsecondary courses for more than the equivalent of one academic year. 5) If a pupil in grade 9, 10, 11, or 12 first enrolls in a postsecondary course for secondary credit during the school year, the time of participation shall be reduced proportionately. B. For purposes of determining PSEO eligibility: 1) An academic year is equivalent to a school year. A school year is defined as July 1 through June 30. 2) If a pupil is in a learning year or other year-round program and begins each grade in the summer session, summer sessions shall not be counted against the time of participation. 3) If a district determines a pupil is not on track to graduate, the limit on participation does not apply to that pupil 4) A pupil who has graduated from high school cannot participate in a program under this section. 5) A pupil who has completed course requirements for graduation but who has not received a diploma may participate in the program. C. An institution shall not enroll secondary pupils, for postsecondary enrollment options purposes, in sectarian, remedial, developmental, or other courses that are not college level unless the student is an alternative education student participating in an approved full-time early/middle college program designed with a well-defined pathway to allow the student to earn a certificate or degree. D. All textbooks and equipment provided to a pupil, and paid for under Minnesota Statute, section 124D.09, Subdivision 13, are the property of the pupil’s postsecondary institution. Each pupil is required to return all textbooks and equipment to the postsecondary institution after the course has ended. For more information on the program and requirements, view the Postsecondary Enrollment Options School Finance webpage at MDE > School Support > School Finance > Postsecondary Enrollment Options.
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